Basic Information
| Provider Information | |||||||||
| NPI: | 1164826384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | L.AC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3339 BUCHANAN ST NE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554181449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122426921 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2833 CHICAGO AVE S | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554073799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128633333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2014 | ||||||||
| LastUpdateDate: | 10/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | 1668 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Acupuncturist |
No ID Information.